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Table 3 Proximal objectives and strategies for programme delivery

From: Synthesising practice guidelines for the development of community-based exercise programmes after stroke

Proximal objectives & recommended strategies Ev n Au Ca1 Ca2 Ca3 Ca4 Ca5 Eu Ne NZ SA Si UK1 UK2 UK3 US1 US2 US3 US4 US5
[41] [37] [42] [38] [43] [1] [44] [3] [48] [36] [49] [45] [47] [35] [39] [40] [34] [2] [46]
8 Personalise programme to individual   5               X X X X X  
  a. Multidimensional pre-assessment conducted by healthcare professional addressing health status, cautions, contraindications and risks 2 7    X       X      X X X X X  
  b. Pre-programme assessment by trainers to enable individualisation of programme 3 3     X           X X     
  c. Adapt programme content to personal situation and goals 2 8 X   X       X    X   X X   X X  
  d. Evaluate programme effects on individual, including satisfaction, functional gains, personal goals, resource use, energy levels 3 3               X X    X  
  e. Supplement group classes with individual sessions 3 1               X      
  f. Sub-divide group classes according to disability levels 3 1               X      
  g. In group classes, conduct functional strengthening exercises together to allow individual monitoring 3 2               X X     
  h. Intensity should be adjusted to the individual 3 4    X          X   X   X    
  i. Pre-programme ECG assessment for exercise level 3 1                 X    
  j. If maximal heart-rate is unknown, use low intensity but increase training frequency/duration 3 3    X             X X    
  k. Shorter, more frequent exercise for frail or deconditioned 3 1    X                 
  l. Use of memory aids where necessary 3 3          X    X   X      
9 Ensure dosage is sufficient to establish and maintain benefits   2        X   X           
  a. At least 3 days/week physical exercise 1 1               X      
  b. 20-30 minutes daily moderate intensity physical exercise 3 2            X X        
  c. Progression: increase load / required effort over time 1 5 X   X          X   X     X  
  d. Aerobic exercise 20–60 minutes, 3–7 days/week; continuous or accumulated 2 2   X               X    
  e. Cardiovascular endurance should be large proportion of activity 3 1                 X    
  f. Strengthening exercises: 4–10 types, 2–3 days/week 3 3    X            X   X    
  g. Flexibility exercises: 2–3 days/week 3 2    X              X    
  h. Coordination & balance exercises: 2–3 days/week 3 2    X              X    
  i. Upper limb exercises 1 hour, 6 days/week 3 1   X                  
  j. Warm-up: 15–20 minutes including range of movement and large muscle group activity 2 2               X X     
  k. Aerobic warm-up and cool-down, 3–5 minutes at lower intensity 2 2    X            X      
  l. Aerobic: up to 10 exercises alternating cardiovascular & local muscle endurance 3 2               X X     
  m. Include home exercises to increase dose 3 4    X X      X      X      
10 Structure programme to facilitate ongoing regular physical exercise   4 X   X            X     X  
  a. Pre-programme contact to discuss any programme barriers 3 3    X            X   X    
  b. Peer/volunteer to accompany to first one or two sessions 3 1               X      
  c. Minimal use of equipment to facilitate home practice 3 1               X      
  d. Promote family / carer involvement 1 10 X   X X      X X   X    X X X X  
  e. Use peer mentoring 2 2          X      X      
  f. Use group format for social support 3 1               X      
  g. Provide opportunities to socialise before and after training 3 2               X X     
  h. Use of mixed media including internet-based and tele-training 2 4          X       X    X X
  i. Locate at home or centre according to personal circumstances / preferences 1 5 X    X   X          X    X  
  j. Locate in own residential environment 1 3      X    X   X          
  k. Provision of transport where necessary, or locate near good public transport links 3 5 X   X          X   X X     
  l. Convenient time 3 1    X                 
  m. Ongoing programme provision 3 2    X            X      
  n. Sign-post to other relevant services / facilities 3 4 X         X    X       X  
11 Ensure adequate staffing numbers to provide safe and effective training   2        X        X      
  a. Instructor: participant ratio: 1:3 to 1:5 3 1    X                 
  b. Instructor: participant ratio: up to 1:8 depending on mix & time since started exercising 3 2               X X     
  c. Supernumerary volunteers or trainees to take part in sessions 3 1               X      
12 Ensure staff are adequately trained for client group   1               X      
  a. Delivered by instructors with knowledge and training in exercise and stroke 3 3    X           X X      
  b. Provide in-service training to instructors 3 1               X      
  c. Ensure stroke-awareness training of frontline staff in course venue 3 1               X      
13 Integrate programme into stroke pathway   3      X          X    X   
  a. Develop partnership agreements between stakeholders 3 1               X      
  b. Referral by healthcare practitioner using clear eligibility criteria 3 2    X            X      
  c. Encourage referring practitioner to visit programme 3 1               X      
  d. Established procedures for transferring responsibilities from referrers to trainers 3 2               X X     
  e. Ongoing communication with (and feedback to) other stakeholders including healthcare professionals, service commissioners, local stroke networks 3 2               X X     
  f. Referral for other treatments where appropriate 3 2               X X     
14 Ensure adequate programme governance   1               X      
  a. Oversight by management group 3 1               X      
  b. Plan for programme evaluation 3 2    X            X      
  c. Use procedures for recording and reporting adverse events 3 2    X            X      
  d. Follow data protection procedures 3 1               X      
  e. Obtain and check ongoing consent 3 2    X            X      
  1. Ev = highest level of evidence presented for strategy.
  2. n = number of guidelines explicitly including objective or strategy.
  3. Au = Australia; Ca = Canada; Eu = Europe; Ne = Netherlands, NZ = New Zealand; SA = South Africa; Si = Singapore.